Home Health Billing — Built for Your Practice
Home health billing under the Patient-Driven Groupings Model (PDGM) is fundamentally different from the old episode-based system. PDGM payment depends on clinical grouping, functional level, and comorbidities — all of which are captured in OASIS coding. Incorrect OASIS coding directly reduces reimbursement.
Our home health billing team specializes in OASIS-E coding, PDGM clinical grouping, and the complete home health claim submission process that maximizes episode payment under the current reimbursement model.
Why Home Health Billing Is Complex
Home health billing complexity includes:
- OASIS-E assessment coding for PDGM clinical grouping
- PDGM 30-day payment period management
- Low utilization payment adjustment (LUPA) threshold management
- Home health face-to-face physician certification
- Therapy threshold coding under PDGM
- Telehealth home health billing under Medicare
- ✓ Specialty-specific denial prevention
- ✓ Certified coders trained on your CPT codes
- ✓ Payer-specific rules for Home Health
Common Home Health CPT Codes We Handle
Our Home Health billing team is trained on every major procedure code — from E&M visits to specialty-specific procedures — ensuring accurate coding and maximum reimbursement.
Not seeing your code? We handle all Home Health CPT, HCPCS, and ICD-10 codes.
Top Home Health Claim Denial Reasons — and How We Eliminate Them
Most Home Health denials are preventable. Our team knows exactly what to look for before submission.
❌ OASIS Coding Errors Reducing PDGM Payment
Inaccurate OASIS functional scores or incorrect primary diagnosis coding results in placement in a lower-paying PDGM clinical group.
✓ Our Fix
We review OASIS-E coding for accuracy and ensure primary diagnosis codes correctly reflect the principal home health diagnosis for PDGM grouping.
❌ Face-to-Face Encounter Not Documented
Medicare requires a physician face-to-face encounter within 90 days before or 30 days after the start of home health care. Missing this documentation results in denial.
✓ Our Fix
We track face-to-face requirements for every new home health patient and flag missing documentation before submitting the initial claim.
❌ LUPA Threshold Not Met
If fewer visits than the LUPA threshold are provided in a 30-day payment period, payment is calculated per-visit rather than at the full episode rate — a significant payment reduction.
✓ Our Fix
We track visit counts against LUPA thresholds and alert agency coordinators when a patient is at risk of falling below the threshold.
❌ Homebound Status Not Documented
Medicare requires patients to be homebound to receive home health services. Insufficient homebound documentation results in denial.
✓ Our Fix
We review homebound documentation for every patient and ensure it includes the specific functional limitations and medical conditions that make leaving home a considerable effort.
Everything Included with ZenoMedix RCM Home Health Billing
- OASIS-E coding for PDGM clinical grouping
- Face-to-face encounter tracking
- LUPA threshold management
- Homebound status documentation review
- Physician certification billing
- Home health PPS claim submission
- Telehealth home health billing
- 98%+ collection rate for home health agencies
Complete Revenue Cycle for Home Health Practices
"Our Home Health practice increased collections by 30% in just 90 days. Phenomenal team."— Practice Manager, Home Health Group
Home Health Billing Available in All 50 States
From California to New York, our Home Health billing specialists understand your state's Medicaid program, payer mix, and compliance requirements.
Find Your State →Home Health Billing FAQ
PDGM (Patient-Driven Groupings Model) replaced the old therapy-threshold model in 2020. Payment is now based on clinical grouping, functional impairment level, and comorbidities — all determined by OASIS-E coding. Our billers specialize in OASIS coding that correctly captures clinical complexity for maximum PDGM reimbursement.
OASIS (Outcome and Assessment Information Set) is the standardized assessment tool for home health patients. OASIS-E scores drive PDGM clinical grouping and payment. Incorrect OASIS coding — even accidentally deflating functional scores — reduces reimbursement for the entire 30-day episode.
Medicare requires a face-to-face encounter between the patient and physician (or qualifying NPP) within 90 days before or 30 days after the start of home health. We track this requirement for every patient and alert your staff when documentation is missing before the claim is submitted.
A Low Utilization Payment Adjustment (LUPA) occurs when a home health agency provides fewer visits than the LUPA threshold for a 30-day episode. Instead of the full episode rate, the agency is paid a per-visit rate that is significantly lower. We track visit counts and alert coordinators before episodes fall into LUPA territory.
Yes. Private duty home health billing uses different codes and billing processes than Medicare home health. We handle T-code billing for Medicaid private duty, hourly billing for commercial payers, and self-pay invoicing for non-covered private duty services.
Home Health Billing Results — By the Numbers
See How Much More Your Home Health Practice Can Collect
- ✓Specialty-specific coding analysis
- ✓Denial pattern review
- ✓Payer mix assessment
- ✓Revenue recovery estimate